Application for Full Membership

There are two ways to join:

1.  Complete the form below, enter credit card information and submit electronically. 
(Once you submit your information you will receive a confirmation message that appears at the top of the screen).

 or

2.  Complete the form below, print and send paper copy of application with check or purchase order to:

ATTUD Management Services Administrator
3 Terrace Way
Greensboro, NC 27403

Personal Information:
Title:
First Name:*
Fields marked with * are required.
Middle Initial:
Last Name:*
Degrees:*
Address:
Position/Title
Department
Organization/
Institution*
Street*
Country*
Other Country
Province/State*
Other State
City*
Postal/Zip Code*
Telephone:*
Format: (000) 000-0000
Fax:
Format: (000) 000-0000
Email:*
Please check the job categories that best reflect your role (choose all that apply). *
Educator/Trainer
Policy Maker
Researcher
Tobacco Treatment Provider
Other If other, please state:

What are your tobacco related job responsibilities? *

Please indicate your primary profession:
If other, please state:
Please indicate your membership in other professional organizations:
(use control + click to select more than one)
If other, please state:

What proportion of your time is spent in clinical activities related to tobacco dependence? *






What is your work setting?*

Academic Institution
Community based
Government Organization
Health Plan
Hospital based
Other Please specify other:


Please describe relevant tobacco related training you have received. *

Signature and Membership Agreement: *
Please read the following statements and check that you agree.
I confirm that the information given in this application form is accurate.
I have read and agree with the mission statement and goals of ATTUD.
I understand that I may not use the name of the organization to promote personal endeavors.
I understand that the organization has the right to accept or decline any application.
I understand that the organization has the right to revoke membership due to unethical conduct.
I confirm that I am tobacco free.
I do not accept any funds from the tobacco industry.
I confirm that I am currently active or have been historically active in the treatment of tobacco use and dependence.
I am electronically submitting my signature by checking here. Date submitted:
Format:YYYY-MM-DD
I do not want to have my contact information included in the member listing section.

Full Membership Category (US $90.00 Annual Fee)
Note: a reduced membership fee ($45.00) is available for applicants from countries of low income based on World Income Classification. The reduction will be automatically applied during the processing of your application.
Select check box if you are from low income based country
Credit Card Payment:
Card Type:
Card Number:
Name on Card:
Billing Address Street:
City
State
Country
Zip Code:
Expiration Date:
Expiration Year:
CVV No.:

or enter promotional code:

Captcha:

Can't read the above security code? Refresh

No application can be processed until payment is received.

The Membership Committee Chairperson or his/her designee will review all information received. Once the the application has been processed, an e-receipt will be sent. If an applicant does not receive the confirmation, they are encouraged to contact the Membership Committee Chairperson, Scott Irwin, PhD, CTTS, myquitcoach@gmail.com.

NOTE: When you submit your credit card information, a confirmation message will appear at the top of this screen. Please only submit once.